Abstract

Background: Although a diagnosis of cancer today may no longer be considered to be the equivalent of a death sentence, many previous studies in Western countries have revealed that such a diagnosis places many kinds of emotional burden on a patient. However, few studies have focused on the nature of psychiatric disorders in Japanese cancer patients.

Methods: We investigated the characteristics, reason for psychiatric consultation and psychiatric diagnosis of cancer patients by analyzing the database of patients referred to the Psychiatry Divisions at the National Cancer Center Hospital and the National Cancer Center Hospital East, Japan.

Results: Among a total of 1721 referrals, most of the cancer patients (78%) were inpatients. Patients with lung cancer (19%) were the most common, followed by patients with breast cancer (13%) and with head and neck cancer (10%). More than half of the patients had recurrent and/or metastatic cancer and 60% of the patients had pain. The most common reason for the consultation was psychiatric evaluation (35%), followed by sleep disorders (19%), anxiety or fear (18%) and depression (18%). Regarding the psychiatric diagnosis, adjustment disorders were the most common (34%), followed by delirium (17%) and major depression (14%). The diagnosis of cancer had been disclosed to more than 99% of the patients.

Conclusion: The common psychiatric disorders observed in Japanese cancer patients were similar to those in the Western countries provided the cancer diagnosis is disclosed.

Received November 6, 2000; accepted January 15, 2001.

INTRODUCTION

Because cancer is potentially life-threatening, the psychological impact of its diagnosis on patients has been an important aspect of clinical oncology. In Western countries, clinical oncology treatment based on truthful disclosure of cancer diagnosis has been provided to patients since the 1970s. After this practice became common, Derogatis et al. reported the prevalence of psychiatric disorders in a random population of 215 hospitalized and ambulatory cancer patients at three major American cancer centers (Johns Hopkins, Rochester and Memorial Hospitals) in 1983 (1). This study revealed that almost half of the cancer patients were diagnosed as having a psychiatric disorder. Most of these patients had either adjustment disorders, major depression or delirium. Massie and Holland reported on the psychiatric disorders in 546 cancer patients from psychiatric consultation data collected during 18 months at the Memorial Sloan-Kettering Cancer Center in New York, USA, and revealed that 54% of the referrals were diagnosed as having adjustment disorders, 15% delirium and 9% major depression (2). Recently, Grassi et al. reported data on 217 cancer patients in a multi-center Italian survey of consultation–liaison psychiatry in oncology and indicated that the most common psychiatric diagnosis was adjustment disorders (27%), followed by major depression (18%) and delirium (11%) (3). These studies in Western countries suggest that many patients with cancer suffer from several kinds of psychiatric disorders and that the common clinical issues are adjustment disorders, major depression and delirium.

In Japan, full disclosure of cancer diagnosis remains controversial and approximately 70% of patients with cancer are not fully informed of their diagnoses (4). To our knowledge, only two previous studies in Japan, conducted by Hosaka et al. (5) and Horikawa et al. (6), investigated the association between disclosure of cancer diagnosis and patients’ psychiatric disorder. Interestingly, both studies indicated similar prevalence rates of psychiatric disorders between cancer patients who had been informed of their true diagnoses and those who had not. On the other hand, the importance of informed consent in cancer care has been recognized recently (7) and the Japanese Ministry of Welfare task force on terminally ill patients recommended in 1989 that informing cancer patients of their diagnoses is essential (8). In some Japanese hospitals dealing with cancer patients, the rate of disclosure of cancer diagnoses has increased (9) and, in some hospitals specialized in cancer care, including the National Cancer Center Hospital and the National Cancer Center Hospital East, almost all cancer patients are informed of their diagnoses (10). However, very few studies have investigated psychiatric disorders among cancer patients in Japanese hospitals that provide cancer care based on truthful disclosure of diagnosis (1114). Furthermore, these studies have excluded patients who had cognitive impairment such as delirium, which is a common psychiatric disorder in cancer patients, and they focused on specific cancers such as breast, head and neck and lung. So, up to now, there have been no data available on the whole range of psychiatric morbidity among various cancer patients in Japan.

The purpose of the present study was to investigate the characteristics, reasons for psychiatric consultation and psychiatric diagnosis in patients referred to the Psychiatry Divisions at the National Cancer Center Hospital and the National Cancer Center Hospital East, Japan.

PATIENTS AND METHODS

All psychiatric consultations referred to the Psychiatry Division, National Cancer Center Hospital East from July 1996 (when the Psychiatry Division was established) to December 1999 and to the Psychiatry Division, National Cancer Center Hospital from January 1998 (when the same database system was established) to December 1999 were reviewed by the authors. A computerized database, custom-made for the Psychiatry Division, National Cancer Center, was used to identify the characteristics, reasons for psychiatric consultation and psychiatric diagnosis of the referred cancer patients. The database included demographic variables such as age, gender, marital status and employment status; medical factors such as cancer site, disease stage, performance status (PS) as defined by Eastern Cooperative Oncology Group (ECOG) criteria, disclosure of cancer diagnosis, in- or outpatient status and pain. The database also includes the reasons for psychiatric consultation and the psychiatric diagnosis. The reasons for psychiatric consultation were assessed by multiple choice based on the description of the physician’s request on the patient chart. For example, if the physician’s request says ‘This patient seems to be anxious. Could you make a psychiatric evaluation?’, the reasons for psychiatric consultation are classified as psychiatric evaluation as well as anxiety or fear. Psychiatric diagnoses including personality disorder were evaluated according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (15).

Patient sheets completed by psychiatrists were automatically read by a mark sheet reader and preserved in the database. All data analyses were conducted using SAS statistical software (SAS Institute, 2000).

The National Cancer Center Hospital has 600 beds and, as of January 1, 2000, the hospital staff comprised 113 staff doctors, 408 nurses and 88 residents (10). By December 1999, 196 871 persons had been treated as inpatients and 194 453 as outpatients. The National Cancer Center Hospital East has 425 beds and, as of January 1, 2000, the hospital staff comprised 58 staff doctors, 239 nurses and 42 residents (10). By December 1999, 5471 persons had been treated as inpatients and 102 894 as outpatients.

Staff of the Psychiatry Division at the National Cancer Center Hospital comprised one staff psychiatrist, two adjunct psychiatrists and two part-time psychiatrists (each available one half-day per week) as of January 1, 2000. Staff of the Psychiatry Division at the National Cancer Center Hospital East comprised two adjunct psychiatrists, two part-time psychiatrists (each available one half-day per week) and one resident as of January 1, 2000. Each Psychiatry Division is independent; however, the psychiatry staffs cooperate with each other and a weekly conference is held to deal with difficult cases and so on. Both Psychiatry Divisions provide two major services, namely a clinic for outpatients and consultation for referred inpatients. Especially the Psychiatry Division at the National Cancer Center Hospital provides psychiatric assessment of all of adult patients before bone marrow transplantation because most transplantation cases are dealt with at the National Cancer Center Hospital.

RESULTS

Characteristics of Referred Cancer Patients (Table 1)

A total of 1721 cancer patients were referred to the Psychiatry Divisions during the study period. The most frequent cancer site was the lung, followed by the breast, then head and neck. More than half of the referred patients were diagnosed as having metastatic and/or recurrent cancer. About 25% of patients had no impairment of physical function (PS of 0) and about 40% were free from pain. More than 99% of the patients had been informed of the cancer diagnosis.

Reasons for Psychiatric Consultation (Table 2)

The most common reason for the consultation was psychiatric evaluation, followed by sleep disorders, affective problems (anxiety or fear and depression) and behavioral problems. Others included patients’ request, presence of psychiatric history, suicidality and pain.

Psychiatric Diagnosis of Referred Cancer Patients (Table 3)

The most frequent psychiatric diagnosis was adjustment disorder, accounting for more than 30% of referred patients. Among adjustment disorders, affective subcategories such as anxiety, depression and both anxiety and depression were much more common than behavioral subcategories (disturbance of conduct). The second most frequent diagnosis was delirium, accounting for about 17% of patients. Of those, more than 70% were of the hyperactive type. The third most common diagnosis was major depression, accounting for about 15% of patients. Other diagnoses included dementia, schizophrenia and anxiety disorders (panic disorder and generalized anxiety disorder); however, each of these diagnoses accounted for less than 3% of patients.

Patient Characteristics and Psychiatric Diagnosis (Table 4)

Patients’ characteristics and the three most common psychiatric diagnoses observed in the referred cancer patients are shown in Table 4. About 25% of referred male patients were diagnosed as having delirium, while about 10% of female patients were diagnosed with the same disorder. Less than 10% of younger patients (<60 years) were diagnosed as having delirium, as opposed to more than 25% of older patients (>60 years). Less than 10% of patients with a PS of 0–2 were diagnosed as having delirium, as opposed to more than 40% of patients with a PS of ≥3. Regarding cancer site, the proportion of adjustment disorders and major depression was highest among patients with pancreatic cancer, while the proportion of delirium was highest in patients with liver cancer.

DISCUSSION

This report provides information about psychiatric disorders in referred cancer patients in two major cancer center hospitals in Japan. Regarding the cancer site, patients with lung cancer, breast cancer and head and neck cancer accounted for more than 40% of all referrals. In Japan, lung cancer is the most common cause of cancer death among men and the second most common among women (17). Furthermore, lung cancer is a refractory form of cancer and was the cause of death of more than 33 000 males and 12 000 females in Japan in 1995. The high frequency and potentially life-threatening nature of lung cancer may be the cause of the high number of requests for psychiatric consultation. On the other hand, because very few studies have focused on the specific psychosocial problems of lung cancer patients (18), further studies are needed to find ways to improve lung cancer patients’ quality of life. Breast cancer is the second most common cancer among women in Japan (19) and it is expected to become the most common cancer in the near future (20). Many previous studies have indicated the serious psychosocial impacts of breast cancer (11,2126), so the high prevalence of the disease and the severe psychological effects of the cancer may be important reasons for psychiatric consultation. Although the prevalence of head and neck cancer in Japan is lower than in Western countries, smoking-related cancer, including cancer of the head and neck, is becoming more common (12). Because patients with head and neck cancer face functional impairment and disfigurement caused by the cancer and/or the treatment, high levels of psychological distress are observed in this population (27). Hence these serious impacts on patients with head and neck cancer may be a reason for psychiatric consultation. Thus, there may be different reasons for the high rates of psychiatric consultation in these three cancer populations.

The findings of the present study give us insights into several other important patient characteristics. One is the disease stage factor. More than half of the referred patients were in an advanced stage of recurrence and/or metastasis, which indicates that strong emotional support is needed for this population. In fact, previous studies investigating the prevalence of psychological distress using rigorous diagnostic instruments in cancer patients indicated that the highest prevalence was observed in patients with recurrent cancer (11). The second important finding is about pain. Of the referred patients, about only 40% were free from pain. The serious impact of pain on patients’ psychological distress has been well established and it is emphasized that psychiatric symptoms in patients with cancer pain must be viewed as a consequence of uncontrolled pain (28). Furthermore, it is now known that cancer pain can be effectively treated in 85–95% of patients with appropriate therapy (29). With this in view, the data may suggest that pain management problems, including appropriate assessment and treatment, remain for cancer patients in Japan.

Regarding the reasons for psychiatric consultation, sleep disorders, anxiety or fear and depression were common. This finding may indicate that oncology staff members are sensitive to these patients’ symptoms and that they consider these symptoms as expressions of patients’ psychopathology. The next most frequent reason was behavioral problems, including management of agitation and of strange or unexplained behavior. The frequency of these reasons was similar to those of consultation–liaison psychiatry in oncology in Western countries (2,3), so these data indicate specific and common characteristics of the consultation–liaison service in oncology.

The present study showed that adjustment disorders were the most frequent psychiatric diagnoses among referred cancer patients. This finding was similar to that of Western studies by Massie and Holland (2) and Grassi et al. (3) and of other prevalence studies conducted in Western countries as well as in cancer center hospitals in Japan, except among such specific populations as terminally ill cancer patients (30). However, psychiatric consultation–liaison data for cancer patients in general hospitals in Japan revealed that when the cancer diagnosis was not disclosed, the most frequent psychiatric diagnoses were organic mental disorders such as delirium and dementia (31). Hence these findings indicate that, if cancer treatment is provided to patients based on disclosure of the cancer diagnosis, adjustment disorders may be the most common psychiatric problem in clinical oncology. As another explanation, we may have to consider the fact that the length of hospital stay has been shortened in Japan. Some patients who were diagnosed with adjustment disorders in this study might be diagnosed with a different psychiatric disorder later, especially major depression, because diagnosis of major depression requires depressive symptoms that persist for at least 2 weeks. Hence the recent change of length of hospital stay in Japan may have an influence on the high prevalence of adjustment disorders.

The next most frequent diagnosis was delirium. To our knowledge, these are the first data providing the prevalence of subcategories of delirium in cancer patients. Among those patients diagnosed as having delirium, approximately 90% had the hyperactive and/or mixed type, characterized by symptoms including psychomotor agitation, and the remaining 10% were diagnosed as having the hypoactive type, characterized by reduced levels of psychomotor activity and alertness. It is noteworthy that only a few delirious patients had the hypoactive type, because an effective management strategy of this type of delirium has not been established as separate from that for the hyperactive and mixed types (32). Only two studies provided preliminary findings about pharmacological intervention to improve hypoactive delirium and those reports indicated the efficacy of neuroleptics (33) and of psychostimulants (34) that have totally different psychopharmacological actions. Because delirium is a common disorder in cancer patients and can also impede communication with their families and hinder their participation in treatment decisions (35), further research is needed to develop an effective management strategy for hypoactive delirium to improve patients’ quality of life.

The next most common diagnosis was major depression. Several previous studies have indicated that there are many serious problems related to major depression among physically ill patients, including cancer patients, and that these not only affect families’ psychological status (36,37), but also patients’ quality of life (38), suicide attempts and suicide (39), requests for euthanasia (40), longer hospital stays (41) and so on. On the other hand, it has been reported that depression in a high percentage of cancer patients goes unrecognized, not only by oncologists (42), but also by nurses (43). Treatment of major depression, especially pharmacotherapy, among patients with cancer is indicated to be effective (4447), so early detection and appropriate recognition of depression in oncology settings should be encouraged.

The findings of associations between referred patients’ characteristics and psychiatric diagnoses revealed that the highest proportions of adjustment disorder and of major depression were among patients with pancreatic cancer. One report indicated that patients with pancreatic cancer experience significantly greater general psychological disturbance, including depression, than patients with other types of cancer (48). This report suggested two possible explanations for this finding: first, that it reflects patients’ greater distress in response to having a tumor with an especially poor prognosis, and second, that a biological, tumor-mediated paraneoplastic syndrome may alter the moods of patients with pancreatic cancer. No clear conclusion has been obtained regarding this association up to now; however, patients with pancreatic cancer may need intensive psychological support. On the other hand, the proportion of patients with delirium was the highest among those with hepatocellular carcinoma. Since it is well known that many patients with hepatic disease develop hepatic encephalopathy (49), this may be a possible explanation. However, very few studies have focused on psychiatric disorders among patients with hepatocellular carcinoma, so further study of this area should be encouraged.

This retrospective study has several limitations. The referred patient sample may have been influenced by physician bias. Also, because this study was conducted in just two institutions in Japan, institution bias may also be problematic.

In conclusion, the common psychiatric disorders observed in Japanese cancer patients were similar to those found in Western countries when clinical oncology treatment is provided based on disclosure of the cancer diagnosis.

Acknowledgments

We thank Ms Yuko Kojima, Ms Ryoko Katayama, Ms Yurie Sugihara and Ms Masae Kamiya of the Psycho-Oncology Division, National Cancer Research Institute East, for their research assistance. This study was supported in part by a Grant-in-Aid for Cancer Research (931) from the Japanese Ministry of Health and Welfare.

+

For reprints and all correspondence: Yosuke Uchitomi, Psycho-Oncology Division, National Cancer Center Research Institute East, 5–1 Kashiwanoha 6-chome, Kashiwa, Chiba 277-8577, Japan. E-mail; yuchitom@east.ncc.go.jp

Table 1.

Characteristics of referred cancer patients

 No.(%)* 
Age (years):  
 Mean ± SD 56 ± 14 
 (median: 58) 
 Range 15–88 
Institution 
 NCCH 841 (48.9) 
 NCCHE 880 (51.1) 
Gender:  
 Male 898 (52.2) 
 Female 823 (47.8) 
Marital status 
 Married 1265 (79.7) 
 Unmarried 213 (13.4) 
 Widowed 108 (6.8) 
Employment status 
 Full time 508 (33.0) 
 Housewife 493 (32.0) 
 Retired 309 (20.1) 
 Others 230 (14.9) 
Setting:  
 Inpatient 1347 (78.3) 
 Outpatient 374 (21.7) 
Cancer site:  
 Lung 322 (18.7) 
 Breast 215 (12.5) 
 Head and neck 179 (10.4) 
 Colon 153 (8.9) 
 Stomach 114 (6.6) 
 Esophagus 101 (5.9) 
 Leukemia 82 (4.8) 
 Pancreas 57 (3.3) 
 Lymphoma 54 (3.1) 
 Liver 44 (2.6) 
 Others 400 (23.2) 
Stage:  
 Recurrence 474 (27.5) 
 Metastatic 461 (26.8) 
 Others 786 (45.7) 
PS (ECOG)‡§ 
 0 421 (24.7) 
 1 496 (29.1) 
 2 296 (17.4) 
 3 266 (15.6) 
 4 227 (13.3) 
Pain 
 Absent 653 (39.9) 
 Mild 408 (24.9) 
 Tolerable 420 (25.6) 
 Intolerable 157 (9.6) 
Disclosure of cancer diagnosis 
 Presence 1656 (99.2) 
 Absence 13 (0.8) 
 No.(%)* 
Age (years):  
 Mean ± SD 56 ± 14 
 (median: 58) 
 Range 15–88 
Institution 
 NCCH 841 (48.9) 
 NCCHE 880 (51.1) 
Gender:  
 Male 898 (52.2) 
 Female 823 (47.8) 
Marital status 
 Married 1265 (79.7) 
 Unmarried 213 (13.4) 
 Widowed 108 (6.8) 
Employment status 
 Full time 508 (33.0) 
 Housewife 493 (32.0) 
 Retired 309 (20.1) 
 Others 230 (14.9) 
Setting:  
 Inpatient 1347 (78.3) 
 Outpatient 374 (21.7) 
Cancer site:  
 Lung 322 (18.7) 
 Breast 215 (12.5) 
 Head and neck 179 (10.4) 
 Colon 153 (8.9) 
 Stomach 114 (6.6) 
 Esophagus 101 (5.9) 
 Leukemia 82 (4.8) 
 Pancreas 57 (3.3) 
 Lymphoma 54 (3.1) 
 Liver 44 (2.6) 
 Others 400 (23.2) 
Stage:  
 Recurrence 474 (27.5) 
 Metastatic 461 (26.8) 
 Others 786 (45.7) 
PS (ECOG)‡§ 
 0 421 (24.7) 
 1 496 (29.1) 
 2 296 (17.4) 
 3 266 (15.6) 
 4 227 (13.3) 
Pain 
 Absent 653 (39.9) 
 Mild 408 (24.9) 
 Tolerable 420 (25.6) 
 Intolerable 157 (9.6) 
Disclosure of cancer diagnosis 
 Presence 1656 (99.2) 
 Absence 13 (0.8) 

*Total: 1721 (100%). NCCH, National Cancer Center Hospital, Japan; NCCHE, National Cancer Center Hospital East, Japan. There are some missing data. §Performance status as defined by Eastern Cooperating Oncology Group.

Table 2.

Reasons for psychiatric consultation (multiple choice)

 No.(%) 
Psychiatric evaluation 599 (8) 
Sleep disorders 325 (9) 
Anxiety or fear 314 (2) 
Depression 302 (5) 
Behavioral management of agitation 137 (8.0) 
Strange, unexplained and bizarre behavior 132 (7.7) 
Patient’s request 106 (6.2) 
Organic brain syndrome 102 (5.9) 
Psychiatric history of non-psychotic disease 72 (4.2) 
Psychiatric history of psychotic disease 70 (4.1) 
Suicide attempt or evaluation of suicidal risk 51 (3.0) 
Pain 35 (2.0) 
Preoperative evaluation 35 (2.0) 
Psychotropic medication assessment 33 (1.9) 
Drug problems 32 (1.6) 
 No.(%) 
Psychiatric evaluation 599 (8) 
Sleep disorders 325 (9) 
Anxiety or fear 314 (2) 
Depression 302 (5) 
Behavioral management of agitation 137 (8.0) 
Strange, unexplained and bizarre behavior 132 (7.7) 
Patient’s request 106 (6.2) 
Organic brain syndrome 102 (5.9) 
Psychiatric history of non-psychotic disease 72 (4.2) 
Psychiatric history of psychotic disease 70 (4.1) 
Suicide attempt or evaluation of suicidal risk 51 (3.0) 
Pain 35 (2.0) 
Preoperative evaluation 35 (2.0) 
Psychotropic medication assessment 33 (1.9) 
Drug problems 32 (1.6) 
Table 3.

Psychiatric diagnosis of referred cancer patients

Psychiatric diagnosis* No.(%) 
Adjustment disorders 585 (34.0) 
 With anxiety 265 (15.4) 
 With mixed anxiety and depressed mood 226 (13.1) 
 With depressed mood 73 (4.2) 
 With mixed disturbance of emotions and conduct 11 (0.6) 
 Unspecified 6 (0.3) 
 With disturbance of conduct 4 (0.2) 
Delirium 299 (17.4) 
 Hyperactive 219 (12.7) 
 Mixed type 48 (2.8) 
 Hypoactive 29 (1.7) 
Major depression 247 (14.4) 
Dementia 36 (2.1) 
Schizophrenia 28 (1.6) 
Bipolar disorder 24 (1.4) 
Panic disorder 15 (1.0) 
Alcohol dependence 14 (0.8) 
Generalized anxiety disorder 12 (0.7) 
No diagnosis 223 (13.0) 
Psychiatric diagnosis* No.(%) 
Adjustment disorders 585 (34.0) 
 With anxiety 265 (15.4) 
 With mixed anxiety and depressed mood 226 (13.1) 
 With depressed mood 73 (4.2) 
 With mixed disturbance of emotions and conduct 11 (0.6) 
 Unspecified 6 (0.3) 
 With disturbance of conduct 4 (0.2) 
Delirium 299 (17.4) 
 Hyperactive 219 (12.7) 
 Mixed type 48 (2.8) 
 Hypoactive 29 (1.7) 
Major depression 247 (14.4) 
Dementia 36 (2.1) 
Schizophrenia 28 (1.6) 
Bipolar disorder 24 (1.4) 
Panic disorder 15 (1.0) 
Alcohol dependence 14 (0.8) 
Generalized anxiety disorder 12 (0.7) 
No diagnosis 223 (13.0) 

*Psychiatric diagnosis is defined by the DSM-IV (15). Subcategories of delirium as defined by Lipowski (16).

Table 4.

Patients’ characteristics and psychiatric diagnosis

Characteristic No.(%) 
 Adjustment disorders Major depression Delirium 
Gender:    
 Male 273 (30.4) 111 (12.4) 218 (24.3) 
 Female 311 (37.8) 136 (16.5) 81 (9.8) 
Age (years):    
 <60 377 (40.5) 130 (14.0) 83 (8.9) 
 >60 207 (26.2) 117 (14.8) 213 (26.9) 
Setting:    
 Inpatient 455 (33.8) 159 (11.8) 293 (21.8) 
 Outpatient 129 (34.5) 88 (23.5) 6 (1.6) 
PS*:    
 0–2 442 (36.4) 182 (15.0) 94 (7.7) 
 3–4 141 (28.6) 63 (25.6) 205 (41.6) 
Pain*:    
 Absent 224 (34.3) 88 (13.5) 47 (7.2) 
 Present 349 (35.4) 151 (15.3) 210 (21.3) 
Cancer site:    
 Lung 116 (36.0) 60 (18.6) 68 (21.1) 
 Breast 94 (43.7) 37 (17.2) 14 (6.5) 
 Head and neck 43 (24.0) 21 (11.7) 46 (25.7) 
 Colon 51 (33.3) 18 (11.8) 24 (15.7) 
 Stomach 39 (34.2) 24 (21.1) 15 (13.2) 
 Esophagus 37 (36.6) 13 (12.9) 24 (23.8) 
 Leukemia 17 (20.7) 5 (6.1) 5 (6.1) 
 Pancreas 27 (47.4) 15 (26.3) 7 (12.3) 
 Lymphoma 18 (33.3) 5 (9.3) 13 (24.1) 
 Liver 13 (29.5) 5 (11.4) 14 (31.8) 
Characteristic No.(%) 
 Adjustment disorders Major depression Delirium 
Gender:    
 Male 273 (30.4) 111 (12.4) 218 (24.3) 
 Female 311 (37.8) 136 (16.5) 81 (9.8) 
Age (years):    
 <60 377 (40.5) 130 (14.0) 83 (8.9) 
 >60 207 (26.2) 117 (14.8) 213 (26.9) 
Setting:    
 Inpatient 455 (33.8) 159 (11.8) 293 (21.8) 
 Outpatient 129 (34.5) 88 (23.5) 6 (1.6) 
PS*:    
 0–2 442 (36.4) 182 (15.0) 94 (7.7) 
 3–4 141 (28.6) 63 (25.6) 205 (41.6) 
Pain*:    
 Absent 224 (34.3) 88 (13.5) 47 (7.2) 
 Present 349 (35.4) 151 (15.3) 210 (21.3) 
Cancer site:    
 Lung 116 (36.0) 60 (18.6) 68 (21.1) 
 Breast 94 (43.7) 37 (17.2) 14 (6.5) 
 Head and neck 43 (24.0) 21 (11.7) 46 (25.7) 
 Colon 51 (33.3) 18 (11.8) 24 (15.7) 
 Stomach 39 (34.2) 24 (21.1) 15 (13.2) 
 Esophagus 37 (36.6) 13 (12.9) 24 (23.8) 
 Leukemia 17 (20.7) 5 (6.1) 5 (6.1) 
 Pancreas 27 (47.4) 15 (26.3) 7 (12.3) 
 Lymphoma 18 (33.3) 5 (9.3) 13 (24.1) 
 Liver 13 (29.5) 5 (11.4) 14 (31.8) 

*There are some missing data.

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Author notes

1Psychiatry Division, National Cancer Center Hospital East, Kashiwa, Chiba, 2Psycho-Oncology Division, National Cancer Center Research Institute East, Kashiwa, Chiba, 3Psychiatry Division, National Cancer Center Hospital, Tokyo, 4Health Science, Hiroshima University School of Medicine, Hiroshima, 5Department of Psychiatry, Kashiwa Hospital, Jikei Medical University, Kashiwa, Chiba, 6Department of Psychiatry, Nippon Medical School, Chiba Hokusoh Hospital, Chiba, 7Department of Psychiatry, Tokyo Women’s Medical University Daini Hospital, Tokyo and 8Department of Neuropsychiatry, Tokyo Medical University Hospital, Tokyo, Japan